NCS000166_Owner Affiliation Designation_20200330

Division of Energy, Mineral, and Land Resources
Land Quality Section / Stormwater Program
- National Pollutant Discharge Elimination System (NPDES)
Energy' Mineral` PERMIT OWNER AFFILIATION DESIGNATION FORM
Land Resources
ENVIRONMENTAL OUALITY (Individual Legally Responsible for Permit)
Use this form if there has been:
FOR AGENCY USE ONLY
Date Received
Year
Month
Day
NO CHANGE in facility ownership or facility name, but the individual
who is legally responsible for the permit has changed.
If the name of the facility has changed, or if the ownership of the facility has changed,
do NOT use this form. Instead, you must fill out a Name -Ownership Change Form
and submit the completed form with all required documentation.
What does "legally responsible individual" mean?
The person is either:
RECEIVED
• the responsible corporate officer (for a corporation); " X
• the principle executive officer or ranking elected official (for a municipality, stafe,edera er public
ffi
agency); DENR-LAND QUAI_IT`(
• the general partner or proprietor (for a partnership or sole proprietorship); STORM NATER FERIA 1117ING
• or, the duly authorized representative of one of the above.
1) Enter the permit number for which this change in Legally Responsible Individual ("Owner Affiliation")
applies:
Individual Permit
N I C I S O 0 10 11 16 16
2) Facility Information:
Facility name:
Company/Owner Organization:
Facility address:
(or) Certificate of Coverage or No Exposure
N C G
Lewiston Mill
Perdue Foods, LLC
3539 Governors Rd
Address
Lewiston NC 27849
City State Zip
To find the current legally responsible person associated with your permit, go to this website:
https://deg.nc.gov/about/divisions/energy-mineral-land-resources/energy-mineral-land-permits/npdes-industrial-
rp ogram and run the Permit Contact Summary Report.
3) OLD OWNER AFFILIATION that should be removed:
Previous legally responsible individual: Wayne
First MI
4) NEW OWNER AFFILIATION (legally responsible for the permit):
Person legally responsible for this permit: Jeff
First MI
Black
Last
Stalls
Last
Page I of 2
S WU-OWNERAFFIL4Nov2019

NPDES Stormwater Permit OWNER AFFILIATION DESIGNATION
Form (if no Facility Name/Ownership Change)
Director of Operations
Title
PO Box 460
Mailing Address
Lewiston NC 27849
City State Zip
(252 ) 348-4271 [e-mail]
Telephone E-mail Address
(410 ) 341-8058
Fax Number
5) Reason for this change:
❑✓ Employee or management change
A result of: Inappropriate or incorrect designation before
❑ Other
If other please explain:
The certification below must be completed and signed by the permit holder.
PERMITTEE CERTIFICATION:
I Kyle Bolin , attest that this application for this change in Owner Affiliation
(person legally responsible for the permit) has been reviewed and is accurate and complete to the best of my
knowledge. I understand that if all required parts of this form are not completed, this change may not be
processed.
Signature
Date
PLEASE SEND THE COMPLETED FORM TO:
DEMLR - Stormwater Program
Dept. of Environmental Quality
1612 Mail Service Center
Raleigh, North Carolina 27699-1612
For more information or staff contacts, please call [phone] or visit the website
at: http://deg.nc.gov/about/divisions/energy-mineral-land-resources/stoirnwater
Page 2 of 2
S WU-O WNERAFFIL-4Nov2019

November 14, 2019
Wastewater Branch
Water Quality Permitting Section
Division of Water Resources
1617 Mail Service Center
Raleigh, NC 27699-1617
Subject: Delegation of Signature Authority
PERDUE FOODS, LLC
NPDES Permit Number NCS000166
To Whom It May Concern:
By notice of this letter, I hereby delegate signatory authority to each of the following individuals for all
permit applications, discharge monitoring reports, and other information relating to the operations at
the subject facility as required by all applicable federal, state, and local environmental agencies
specifically with the requirements for signatory authority as specified in 15A NCAC 213.0506.
Individual 41 Individual #2 (if applicable)
Marne:
Jeff Stalls
Title:
Director Of Operations
Mailing Address: !
Po Box 460
Lewiston, Nc 27849
Physical Address:
(f d fferent)
3539 Governors Rd
Lewiston, Nc 27849
Email Address:
jef£[e-mail]
Office Phone:
252 - 348 - 4271
- -
Mobile Phone:
252 - 209 - 4178
- -
If you have any questions regarding this letter, please feel free to contact me at 410-543-3227 or
[e-mail].
Sincerely,
Kyle Bolin
Vice President Of Operations
31149 Old Ocean City Rd, Salisbury, MD 21804
[e-mail]
410-543-3227
cc: Washington Regional Office, Water Quality Permitting Section